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Executive Summary

Objective and Directives

This report describes the development, testing, and implementation of a model
to enable community health call centers, such as poison control centers,
nurse advice lines, and other hotlines, to support home-management and shelter-in-place
approaches in certain mass casualty or health emergency events. To guide
call centers in adapting to accommodate such emergencies, we developed four
specific products:

For the four National Planning Scenarios for which call centers had the
best capabilities, a detailed list of all the applicable capabilities
(Appendix 2).

Suggested elements for public health information and decision support
hotlines. (Appendix 3).

Four fully detailed interactive response applications that allow callers
to use their touch-tone phones to automatically retrieve critical information
during a public health emergency
(Appendix 4).

These products were developed for the four specific planning scenarios but
can be adapted to others as appropriate. Together, they cover the full range
of capabilities that community health call centers can provide.

To develop these products, Denver Health responded to five specific directives. The
results for each are summarized here.

Results and Recommendations

We convened a national advisory panel of 13 subject matter experts with
backgrounds and experience in fields that we considered crucial to community
and national response planning as it relates to health call centers.

In addition, we invited representatives from several key Federal agencies to
participate, including the Department of Health and Human Services, Department
of Homeland Security, and Department of Transportation, as well as the American
Red Cross. Panelists and agency representatives convened at three advisory panel
meetings and the final presentation meeting in Washington, DC.

At these meetings,
agency representatives educated the panel and core team members on the current
Federal response efforts under way and how this project would best integrate
with or support those efforts. The core team described the potential response
capabilities that community health call centers could provide in responding
to specific scenarios and proposed strategies and resources for assisting
them in such responses. The expert panelists provided guidance on the development
of the strategies and resources and helped refine them for the greatest utility
and exportability.

We used the Department of Homeland Security's (DHS) National Planning Scenarios
to ensure consistency with other preparedness and response efforts that are
being developed. While these scenarios do not cover all possibilities for
health emergencies, they do include a wide spectrum of disasters that communities
could face. Though many other disaster scenarios have been developed, the
DHS scenarios were developed with the participation of numerous Federal agencies.

We reviewed all 15 scenarios and determined which ones could benefit from use of the
potential response capabilities of community health call centers. We then
developed a matrix that lists each scenario, including expected casualties,
infrastructure damage, evacuation/displacement of persons, sheltering,
and victim care strategies. We focused development of our model on scenarios
with the following characteristics:

The community infrastructure was expected to remain intact so that call
centers would be operable.

Major public health outcomes would be involved.

The scenario had the potential for many "worried well" (those
with little or no injury who could overwhelm health care delivery systems),
who could benefit from home management or sheltering in place.

We determined that four biological related scenarios (Biological Attack—Aerosol
Anthrax, Biological Disease Outbreak—Pandemic Influenza, Biological
Attack—Plague, and Biological Attack—Food Contamination) afforded
the best opportunity to involve all potential response capabilities for community
health call centers. Furthermore, our team and the panel believed that many
response capabilities for biological incidents could also be used to address
the response needs of chemical, radiological, and natural disasters. The
broader application of health call center response capabilities to meet the
needs of all 15 scenarios is discussed in this report.

3. Research existing models, protocols, and algorithms; develop and implement
a scenario-based model using poison control centers, nurse call lines, and
similar centers

We researched whether there were proven or experimental models for health
call center responses to the four selected scenarios or any closely related
scenarios. Searches of the published literature, public health practices,
and Internet resources produced only limited results related to our objective.
Many local and State public health department Web sites provide flu vaccination
clinic information, searchable by city name or zip code. A few health departments
also had telephone information hotlines that used either standard recorded
messages or live agents to provide specific clinic locations or general influenza
information. We did not locate any operating examples of interactive automated
telephone-based systems for providing information to or collecting information
from the public during health emergencies.

We found published reports describing the use of call center capabilities for responding
to health events relative to the four biological scenarios of interest:

An influenza hotline conducted a vaccination survey during an influenza
season with a vaccine shortage. The hotline addressed questions from the
public regarding vaccine availability, groups most at risk, and symptoms
in order to reduce inquiries to physician offices and local health departments.
The authors suggested that State health departments consider a hotline
to educate the public regarding influenza vaccination and to follow up
with callers who were advised to receive vaccination to improve compliance.

A health department in Canada provided SARS information to the public
through a hotline and supported the management of more than 10,000 individuals
placed in quarantine, mainly in their own homes. The hotline required more
than 200 health department staff to support its operations over a 3-month
period.

A health department in the United States used videophones to monitor
suspected SARS cases and their close contacts. Afterwards, the equipment
was used to monitor patients with active and latent tuberculosis.

Health officials in Taiwan quarantined more than 130,000 people, mostly
in their homes, for 10 to 14 days to prevent the transmission of SARS.
Management of those in quarantine consisted of daily visits or telephone
calls to review the person's current health status, including temperature
recordings and symptoms.

Four populations (Hong Kong, Taiwan, Singapore, and the United States)
were surveyed about attitudes regarding the use of preventive measures
to control the spread of a contagious disease. Support for any preventative
measure decreased significantly if the condition of arrest for refusing
to comply was added. The most favored methods of monitoring quarantine
compliance were daily visits from health officials and periodic telephone
calls. In the United States, the majority of respondents favored home quarantine
for themselves and their families.

These reports suggest that using the telephone to provide information and support
disease control measures such as home quarantine would likely be favorably
received by the public and would assist public health agencies in the management
of such efforts. Indeed, our experiences in operating a health call center
that provides poison and drug information and nurse triage recommendations
suggest that the public will seek out such community resources during health
emergencies. We developed the Health Emergency Line for the Public (HELP)
program to provide information and decision support to the public related
to health events in Colorado.

In this report, we provide the HELP model blueprint so that other health call centers
can consider developing these response capabilities. We also present health
call-center-based information tools that use technology to better handle
surges in demand, such as an Interactive Response (IR) system that allows
callers to use their touch-tone phone to automatically retrieve information.

We focused the resource development on five health call center response capabilities:
health information, disease/injury surveillance, triage/decision support,
quarantine/isolation support, and outpatient drug information/adverse event
reporting. We did not address the mental health assistance/referral capability
as a specific health call center component, but included suggestions to reduce
community anxiety and panic in the resources and strategies that we developed
for the other five response capabilities. We assessed each response capability
for: significance, applicability to scenarios, current examples, range of
support technology, and staffing required. We then proposed resources and
strategies for each capability.

Health Information. Use of health call centers could
greatly augment mass risk communication messages and help to alleviate
surges to health care systems. Our experience and that of others has shown
that incidents generating public concern usually require robust mass risk
communication strategies coupled with hotlines or other forums to assist
those with further needs. Providing health information is applicable for
all National Planning Scenarios; however, the best association of health
call center expertise and community need is for: Aerosolized Anthrax, Pandemic
Influenza Outbreak, Plague Outbreak, and Food Contamination.

We developed an instructional guide for community health call centers to
develop a health information capability consistent with that of the HELP
program (Go to Appendix 3,
Suggested Elements for Public Health Information
and Decision Support Hotlines). We describe the components that we found
to be essential for developing a standardized response capability. These
components provide us with the platform onto which additional capabilities
could be added to support outpatient health care and monitoring during public
health emergencies. This response model for public health events includes
providing consistent, accurate information, collecting and maintaining structured
data to characterize events and responses, and developing capability and
capacity to adapt to other public health emergencies.

We also developed two applications for providing automated information to
callers, especially important in events that could generate call volumes that
surpass call center staff ability to answer calls. These two applications were
developed for use with an IR system to allow callers to use their touch-tone
phone to retrieve information. One IR application allows callers to get zip
code-specific messages and was developed specifically for finding
point-of-dispensing (POD) locations to get medications during
an event requiring community prophylaxis. The Cities Readiness Initiative
program of the Centers for Disease Control and Prevention (CDC) recommends
POD mechanism development as a key element of readiness. The other IR application
allows callers to navigate through a library of Frequently Asked Questions
(FAQs) to retrieve information relative to their concern. Both applications
ensure consistent and accurate information delivery: the same information
is provided to every caller, every time.

Though the applications were developed for use with an IR system, they could be
used without such technology. The call flows, decision trees, and message
scripts could be used to guide call center staff in how to handle calls or
could be used with other technology such as recordings and announcements
to assist call center staff in managing higher call volumes. The POD application
could be modified to provide any information based on zip codes, such as
in evacuations, sheltering in place, snow cancellations, or mass vaccinations.

Disease/Injury Surveillance. Call centers that collect any
health data could contribute to surveillance systems to quantify illness/injury
(situational awareness) or to detect sentinel events or emerging health threats.
Some health call centers may already analyze their own data to characterize
their patient populations, while others may not realize the value of their
data as it relates to a public health agency's need for disease and
injury surveillance. The National Planning Scenario with the best association
between health call center expertise and community need for disease/injury
surveillance was the Pandemic Influenza Outbreak scenario, though almost
all of the other scenarios could benefit from using call centers to capture
health data for disease or injury surveillance.

For example, the American Association of Poison Control Centers contributes to
disease surveillance by transmitting data related to toxic substance exposures to
the CDC's BioSense program. That program is an initiative to
develop a national biosurveillance capability that seeks to improve the Nation's
capabilities for disease detection, monitoring, and real-time situational
awareness through access to existing data resources.

Triage/Decision Support. Health call centers can assist with
triage and decision support for health concerns and can alleviate surges
to health care facilities, thereby reducing unnecessary hospital visits
and associated health care costs. The National Planning Scenario with the
best association between health call center expertise and community need
for this capability was the Pandemic Influenza Outbreak scenario. However,
almost all of the other scenarios could benefit from using call centers
to assist with the triage and management of disease or injury, especially
in preventing the "worried well" from overwhelming health
care facilities.

Current examples of this capability include poison control centers that triage
poisoning and provide exposure management support, and nurse advice lines that
triage symptoms and provide symptom/disease management support. Both call center
types provide such services with licensed clinical professionals on a daily
basis, and this strengthens their credibility with the public. Research has
shown that such centers reduce health care costs by preventing unnecessary
emergency department visits and hospital admissions. Therefore, using these
trusted call centers in health emergency situations should result in the
same efficiencies and cost effective outcomes.

The HELP program does not use clinicians but provides disease and symptom information
for the caller to use in making decisions for their own health care. Such
an approach reduces the need to have clinicians—a finite resource that
will be in high demand during any health emergency—on staff. For normal
daily operations, trained information providers deliver scripted information
and refer callers requiring exposure, symptom, or injury triage, as well
as management support, to appropriate resources such as a poison center,
nurse advice line, or health care provider. Using information providers to
handle most public information needs prevents unnecessary calls to clinician-staffed
lines so that they can continue to handle medical triage and management support
calls.

Communities should consider the clinical recommendations they would use in the event
of a major health emergency, such as pandemic influenza, that severely affects
the health care delivery system. The health care delivery system and health
care providers need to consider how they would handle a surge of sick patients
in the face of increased demands on limited health care resources. A health
call center needs to ensure that its recommendations are consistent with
those of the rest of the health care delivery system and its health care
providers.

Quarantine and Isolation Support. Health call centers are well suited to
assist with monitoring or contacting those in quarantine and isolation,
especially if they have appropriate guidance and resources. Research indicates
public support for quarantine to control disease and for monitoring
the status of those in quarantine by telephone. The two National
Planning Scenarios involving infectious diseases (Pandemic Influenza Outbreak
and Plague Outbreak) would potentially require the use of quarantine and
isolation as disease control measures and could benefit from using call
centers to support such measures. Future SARS and other infectious disease
outbreaks would require planning and response capabilities similar to those
for the influenza and plague scenarios.

Telephones were used to monitor those in quarantine in the SARS outbreaks
in Toronto and Taiwan, and less than one percent of those in quarantine developed
symptoms or were noncompliant. Simply having a staff person contacting those
in quarantine can attain this response capability, but larger numbers of
people in quarantine will require more automated approaches for monitoring
health status and compliance. We developed a Quarantine/Isolation (QI) Monitoring
Application (Go to Appendix
4, Developing an Interactive Response Tool) that uses an
IR system and frees staff to handle only those needing further attention,
such as those developing symptoms or those who did not answer earlier calls.
Since most in quarantine should require only periodic monitoring, automating
much of that with the QI Monitoring Application could be of great utility.

The QI Monitoring Application automatically places calls to individuals in home
quarantine to assess their current health status and reports on those that
don't answer so that further followup can be conducted. The application
is part of an IR system that can initiate up to 12,000 calls in a ten-hour
period. Though this application was developed for use with an IR system,
it could be used without such technology. The call flows, decision trees,
and message scripts could be used to guide call center staff in handling
calls in a structured manner. The application could be adapted to other scenarios
that might require contacting individuals by telephone for sheltering in
place strategies. We recommend that public health agencies develop referral
protocols and guidance for call center staff in handling situations in which
a quarantined individual needs food, medication, or financial assistance.

Outpatient Drug Information/Adverse Event Reporting. The CDC's Cities
Readiness Initiative program requires that participating cities prepare
plans for mass prophylaxis with Strategic National Stockpile assets. Depending
on exposure, this program could result in thousands to millions of people
being dispensed antibiotic medications. Health call centers can support
these efforts by providing information about the incident and the supplied
medications, as well as by collecting any potential adverse event reports.
The two National Planning Scenarios involving agents that would be treated
with antibiotics are Aerosolized Anthrax and Plague Outbreak, but other
scenarios that involve either mass vaccinations (Pandemic Influenza Outbreak),
wide-scale use of medications for treating radiation exposure (Nuclear
Detonation, Radiological Dispersal Devices), or Food Contamination may
also require this response capability.

We have developed an application that would support mass prophylaxis with antibiotic
drugs using an IR system. The Drug Identification (DI) Application assists
callers in identifying dispensed drugs, provides information on how to take
them, and describes potential adverse reactions. This would allow public
health agencies to concentrate on operating mass dispensing sites and health
care providers to care for those that develop illness. Though this application
was developed for use with an IR system, it could be used without such technology
to guide call center staff in how to handle these calls. The application
could be adapted to other scenarios that might require mass administration
of medications or vaccinations and provision of relevant information.

MentalHealth Assistance/Referral. Health call centers providing
health information and support will help relieve anxiety and stress among
the public, especially since many such centers are known and trusted resources
within communities. All 15 of the National Planning Scenarios will
likely result in varying degrees of community fear, panic, anxiety, and
depression. Countless suicide prevention and counseling hotlines currently
exist and are run by trained mental health staff. The National Suicide
Prevention Lifeline provides a 24-hour toll-free service that routes callers
to crisis centers across the country. Additionally, nurse advice lines
are capable of handling patients with depression, and poison control centers
regularly receive suicide and intentional harm calls. Health call center
staff can be trained to identify callers that may benefit from a referral
to community mental health resources.

4. Develop a mechanism to test and evaluate the model with a local exercise

The HELP model has been tested over 3 years of daily operations and in response to
several major health events. The HELP model has made it possible for us to
provide consistent, accurate, and up-to-date information during bioterrorism
exercises and public health emergencies in partnership with the Colorado
Department of Public Health and Environment. The HELP program provides a
model for disseminating and collecting information that, to date, has involved
handling more than 75,000 calls related to several major health events, including
West Nile virus (WNV) and influenza outbreaks. The public's demand
for information during these events has required us to develop better strategies
for delivering such services with limited staffing resources.

One strategy is to use initial announcements to relay the information most requested
by callers to reduce their need to speak with staff. On average, 60 percent
of callers listen to the recorded information and terminate the call, indicating
that their concern was addressed with the announcement. This has remained
fairly constant for a range of health events over the last 3 years. Additionally,
recordings of other frequently requested information can be cycled to potentially
answer callers' questions while they are waiting to speak to staff.

Many callers may get the information they require from those messages and
no longer need to wait for assistance. This ensures that staff is assisting
those that could not be helped easily by other means. Recordings can also
refer callers to other information sources, such as the Internet, that they
may opt to explore instead of waiting in queue. By reviewing the concerns
of callers speaking with staff, managers can determine if additional information
should be added to the initial announcement or queue messages, or disseminated
by the media or other sources in hopes of meeting demand without call center
staff involvement.

The challenges we have encountered with surges in demand for HELP have led us to
produce applications to better assist in providing information and supporting caller
needs during health emergencies. Using technology such as an Interactive
Response (IR) system has further improved our capacity for handling high
call volumes. We have developed and tested four IR applications that we believe
other community health call centers can use, as well:

Quarantine/Isolation (QI) Monitoring

Point of Dispensing (POD) Locations

Drug Identification (DI)

Frequently Asked Question (FAQ) Library

A prototype version of the QI Monitoring Application was tested in a rural user group
(N=12) in conjunction with an influenza vaccination exercise in October 2005.
The prototype application was revised to reflect many of the user suggestions.
The revised and more fully developed QI Monitoring Application, along with
the other three applications, were evaluated in an exercise in May 2006 in
an urban user group (N=96) consisting primarily of local health personnel
from 10 counties. The goal of the second exercise was to test the ability
of the four IR applications either to initiate contact and determine health
status of those in quarantine (QI Monitoring) or to effectively communicate
key information to users calling into the four applications.

We met our overall exercise objectives, and we obtained excellent feedback to help
us improve the tested applications. We also obtained important information
on user acceptance of these IR applications. Although evaluations for all
four applications were mostly favorable, it was apparent the FAQ Library
application seemed more acceptable than the DI application, perhaps because
the latter concerned medications that callers were asked to take.

The comments and evaluations of these applications should also help Public Information
Officers in determining which ones may be acceptable for different events
and in developing messaging strategies for those events. These results also
suggest areas for potential community outreach efforts for public health
agencies to create a more informed public. One lesson learned is that the
applications will be only as good as the information that is developed for
them and the means by which that information is provided to the public.

5. Prepare a final report and recommendations

This final report describes in detail areas described above: the model, the scenarios
where the model could be used effectively at various levels of response,
and a comparison of the model to other existing models. A brief summary of
recommendations follows.

To help
the public make informed decisions and care for themselves during severe
health events, such as disaster scenarios, we must plan ahead to develop
strategies that will minimize or alleviate surge on health care delivery
systems and accommodate those most in need. Helping community health call
centers develop response capabilities through the models and applications
in this report can increase their ability to support the public.

We believe, as determined, in conjunction with the advisory panel, that the four biological
scenarios from the Department of Homeland Security National Planning Scenarios
described above afford the best opportunity to involve most of the potential
response capabilities for community health call centers.

The target audiences for the proposed scenario-specific models and applications are
community health call centers that are established and trusted community
resources, including:

Poison control centers.

Nurse advice lines.

Drug information centers.

Health agency hotlines.

Local/State/Federal public health agencies.

The resources that we have developed to support outpatient
health care and monitoring during health emergencies with limited staffing
will allow other health call centers to meet the challenges of surges in
demand related to health events. These resources will provide the public
with self-service support so that persons can make appropriate informed decisions
about their health concerns. The basic call center infrastructure and essential
elements of the HELP program are needed to support such strategies.

The HELP Models Interactive Response Tool and its four applications proposed
in this report are not sole components but part of a comprehensive public
information strategy that includes the use of mass media and community health
call centers to support self-care, monitoring, appropriate referrals, situational
awareness, and disease outbreak management and control.